Perception of Humanitarian Medicine by Military and Political Stakeholders
Paul Bouvier
Humanitarian Medicine and the Mirrors of Perception
Compared with other human activities, humanitarian assistance enjoys a globally positive perception in our contemporary world. By contrast, military, political, or commercial activities may arouse rather negative perceptions. This may induce some stakeholders to associate with humanitarian assistance in order to globally improve their image and be perceived in a more positive light by local people. In armed conflicts, however, blending humanitarian aims with military, political, or commercial goals often leads to a blurring of objectives and a confusion of roles. This could in turn change the perception and acceptance of humanitarian action by potential beneficiaries and other stakeholders.
On the other hand, armed conflicts have catastrophic effects on the health of populations, and the provision of medical care to populations affected by armed conflicts responds to major health needs (Levy and Sidel, 2008). Furthermore, political authorities and military forces have a duty to provide medical care to the wounded and sick and to the affected populations.
Based on some examples, this article will explore the risks associated with medical programs designed to influence perceptions, and the conditions which should be respected by stakeholders in the provision of medical assistance in armed conflicts.
Military Medical operations for Populations Affected by Armed Conflicts
During the Vietnam War, the US military introduced a new kind of medical program inside the combat operation, the Medical Civic Action Programs (MEDCAP), defined as “the use of military medical personnel and resources to treat the native population.” This program would become a significant operational activity, with about 40 million encounters between American military physicians and Vietnamese civilians, at a cost of $500–750 million, from 1963 to 1971 (Wilensky 2004).
The program was conceived as a way to improve perception by the population of South Vietnam, with the objectives “to enhance the prestige of the Government of Vietnam in the eyes of the people” and “to win the confidence, and gain the cooperation of the local population in areas where relatively large US military forces are employed” (Eisner 1966). In addition to the political goal to “win the hearts and minds of the people,” (Wilensky 2004), there were tactical objectives as medical care could yield useful intelligence. However, it seems that the program didn’t have significant public health impact, and questions are raised over whether it was lacking relevant and efficient approaches. Opportunistic, poorly planned, and isolated medical visits to remote villages could only provide, at best, transient relief of diseases and ailments, but couldn’t have any significant lasting impact on the health of the population. However, the primary concern seems to have been perception by the population rather than community health impact. A doctor involved in the program wrote in 1966 that “MEDCAP, to be effective, must be on a regularly scheduled basis. A single visit to a hamlet produces no lasting impression, but regularly scheduled sick call is a potent factor in demonstrating to the people that their government and their allies have a continuing interest in their welfare” (Eisner 1966). Obviously, for this practitioner, MEDCAP activities in Vietnam were about people’s perception. Indeed, the medical care provided by “sick-call patrols” in remote villages was extremely limited and rudimentary. There is no evidence that capacities developed by US doctors transferred to South Vietnamese medical personnel; on the contrary, these programs may have emphasized the inability of the Republic of Vietnam to provide basic health care to its own people. The ethics of this practice were also questionable (Malsby 2008).
MEDCAP operations recently returned to activity in Iraq and Afghanistan. They started in a rather improvised way before integrating into a strategy aimed to “win hearts and minds.” Whereas their impact on the health of the population remains unknown, military health authorities have been rather enthusiastic about their impact on the perception of the US military by the local population (Cascells 2009). In 2009 the approach developed into a new concept, the Medical Stability Operations (MSOs), which would build on the experience of MEDCAP in a more professional and effective way (Pueschel, 2009). Recognizing the limits of MEDCAP, the new strategy seeks to learn from this experience and to collaborate with humanitarian organizations (SOMA conference, 2009). In order to facilitate collaboration with humanitarian actors, the US military forces have created a guide covering its interaction with NGOs: “The guide shows how the military can work with NGOs that may not want to be perceived as being aligned with people in uniform on the ground” (US DoD, Jan. 2010).
A supplementary role is recognized for NGOs: “In many cases NGOs can operate in space Department of Defense (DoD) can’t. They can move faster through customs, etc., and many NGOs have been in countries longer than DoD and have experience. NGOs prefer to maintain neutrality from the government, so there is an inherent friction between them and DoD. There are some NGOs that have former military members in them that are more amenable to working with DoD, and then a wide range of other international and local NGOs.” (Pueschel 2010). Interestingly, while they recognize that NGOs can access vulnerable populations that military medical services couldn’t reach, the authors fail to see that this access is only possible because these humanitarian NGOs remain absolutely neutral to the conflict and independent from governments and military forces. Even more worrying is the perception of humanitarian neutrality as a cause of tension between humanitarian actors and armed forces.
In May 2010, the US DoD announced a new policy which “elevates the importance of military health support in stability operations, called Medical Stability Operations (MSOs), to a DoD priority that is comparable with combat operations” (US DoD, May 2010).
Medical Assistance to War Wounded in Afghanistan
At about the same time, the ICRC published an operational update article about the medical assistance to war wounded persons in Kandahar. In this article, the ICRC reiterated that it provided basic first-aid training and dressing kits to arms carriers and to civilians living in conflict areas, and stated that in April it reached “over 70 members of the armed opposition” (ICRC May 2010). In fact, since 1987 the ICRC has provided medical assistance across Afghanistan, to care for conflict victims and to provide neutral, independent support to health structures and staff across Afghanistan (ICRC 2009). Training first aid workers living in remote areas of conflict is part of this humanitarian assistance. These training sessions are also a unique opportunity to disseminate humanitarian principles.
The ICRC’s operational update triggered critical reactions in international media, and the organization had subsequently to justify its action, explaining that “It’s the core of its mandate to make sure that people are cured whether they are from one side or the other side” (the Guardian, the Huffington Post, USA Today, 2010). This episode revealed how fundamental humanitarian principles such as impartial care to wounded persons and medical neutrality could become a matter of controversy in international media—even when they were accepted by armed forces in the field. It also provided the ICRC with an opportunity to reaffirm the vital importance of respecting those humanitarian principles.
Perception of Humanitarian Principles in the Media and in the Field
In striking contrast with controversies in international media regarding the neutrality of medical action in conflicts, persons directly affected by armed conflicts and wars affirm the vital importance of these humanitarian principles.
This was recently demonstrated by a survey, published by the ICRC in June 2009, about the perception of humanitarian principles by people in countries in war (ICRC 2009). About 4,200 persons from eight countries affected by armed conflicts were interviewed, notably about their views regarding provision of health care to victims of conflict. Ninety-six percent of all participants agreed that “everyone wounded or sick during an armed conflict should have the right to health care.” For 89 percent, “Health workers should treat wounded and sick civilians from all sides of a conflict”; and 89 percent agreed that “Health workers must be protected when they are treating wounded or sick enemy combatants, especially when treating enemy civilians.” For 89 percent, under no circumstances is it acceptable for combatants to target health workers in a situation of armed conflict, and 87 percent agreed that combatants should never target ambulances.
This important study demonstrates that, for the populations living in contexts of armed conflict, despite all the suffering and losses endured during war, the principles of humanity and impartiality and the respect of medical neutrality are essential.
Medical Assistance Must Have Strong Ethics
The devastating effects of armed conflicts on the health of populations and on their access to medical care represent major challenges to the political and military authorities. Medical care and public health programs should be provided in response to the health needs of the populations affected by the conflict and not driven by strategic goals.
In many contexts, political and military stakeholders face enormous difficulties in organizing services and providing medical care to vulnerable populations. Much can be learned from the experiences of the US military forces in Vietnam or in Afghanistan (Malsby 2008). The recent evolution from MEDCAP programs to an MSO policy could improve the efficacy and pertinence of these interventions.
In a different context, the activity of first-aid workers in Afghanistan working in very insecure and deprived conditions poses very difficult challenges. In these situations, as in any other context, the sole and unique purpose of health care assistance should be to respond to the needs of sick and wounded persons. Health care must be impartial and medical neutrality must be respected by all parties at all times. Health personnel shall never engage in acts of war, and the provision of health care must always respect the principles of medical ethics (Sidel and Levy 2008). The insertion of political or military goals into medical or public health programs is not compatible with the fundamental principles of international humanitarian law.
Stakeholders should be extremely cautious when faced with the temptation to use any form of humanitarian assistance for the sake of their image or perception. Most importantly for them, populations affected by armed conflicts actually understand their own needs and recognize the importance of neutrality and impartiality in the provision of health care. It is comforting that, even when some media raise controversy on neutral and impartial humanitarian action, the affected populations demonstrate their commitment to ethical and humanitarian principles. They know by experience, with their blood and tears as much as with their hearts and their minds, that even in armed conflicts, respecting principles of humanity and ethics is a vital matter.
Footnotes
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